SGS Krav Maga Registration Page Register Now! STUDENT DETAILS no spaces Birthdate* How did you hear about us?* Emergency Contact* PHYSICAL READINESS QUESTIONNARE All answers required* 1. Has your doctor ever said you have a heart condition or vascular disease? YesNo 2. Do you ever experience chest pains? YesNo 3. Have you experienced any chest pain recently? YesNo 4. Do you ever feel faint, dizzy, lose balance or lose consciousness? YesNo 5. Has your doctor ever said you have high blood pressure (140/90)? YesNo 6. Are you taking any medication for blood pressure or a heart condition? YesNo 7. Are you a male over 35, or, a female over 45 and not accustomed to exercise? YesNo 8. Do you have a bone or joint problem that could be made worse by a change in your physical activity? YesNo 9. Do you suffer from asthma? YesNo 10. Do you suffer from any other respiratory problems? YesNo 11. Do you suffer from diabetes? YesNo 12. Do you suffer from epilepsy? YesNo 13. Do you currently suffer from any illness not mentioned here? YesNo Please specify: 14. Do you know of any other reason why you should not participate in physical activity? YesNo Please specify: NOTE: If you have answered YES to any of the above questions, you are required to provide a licensed medical practitioners certificate/clearance before you will be allowed to participate. 15. Do you suffer from any allergies? YesNo Please specify: Additional Notes/Special Requests TERMS & CONDITIONS I hereby enroll in SGS Krav Maga self defence and/or fitness training on the basis of the terms and conditions set out below: 1. I acknowledge that the training, while conducted in the safest possible conditions and under qualified supervision, involves physical contact and inherent risks and I accept those risks. I agree to conduct myself in a safe and mature manner and in accordance with the instructions from my instructors. I indemnify SGS Krav Maga, its proprietors, agents and officers, and Krav Maga Global, including all instructors, staff members, and students against any loss or damage suffered by them in connection with my participation in the training. 2. I confirm I am physically capable of participating in this training and that I have no existing medical condition/s which precludes or should reasonably preclude my participation. I have received clearance to train from my own licensed medical practitioner/s in any areas of personal concern. 3. I agree to release SGS Krav Maga, its proprietors, agents and officers, and Krav Maga Global, including all instructors, staff members, and students from any liability whatsoever in connection with my participation in this self defence and/or fitness training program. Without limitation, this includes all loss or damage or injury incurred as a direct or indirect result of my participation. 4. I agree that I will conduct myself in an appropriate manner and will always act in a manner that is in the best interests of SGS Krav Maga and Krav Maga Global. 5. I understand that audio and/or images (moving or still) may be taken of me during training for the purposes of promotion and advertising. I give my consent and release for these to be used by SGS Krav Maga and Krav Maga Global. I understand I have the right to refuse to allow my images to be used and if this is the case, I have spoken personally with the senior instructor and it will be so noted on the bottom of this form. 6. I confirm that I do not have a criminal record and I am not involved with or a member of any criminal organization. 7. If I am under 18 years of age, I have obtained my parent’s consent to my participation and to the above mentioned terms and conditions. I / WE AGREE TO THE ABOVE TERMS & CONDITIONS I have read and understand the terms and conditions. To the best of my knowledge I have answered the questions above truthfully. I understand and agree that it is my responsibility to inform SGS Krav Maga of any conditions or changes in my health, now and on going, which might affect my ability to participate safely in exercise. YesNo if under 18years of age. IMPORTANT: Please print off the form attached to your confirmation email and bring along with you on the night. Privacy Statement The personal information contained in this document is to provide contact information/medical details for individuals wishing to train with SGS Krav Maga. This information may be disclosed to other staff members, agents and instructors of SGS Krav Maga and of Krav Maga Global, medical practitioners and/or other third parties should there be an issue or medical emergency, and in accordance with the Information Privacy Act.